A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?
"It sounds like you’re concerned about your privacy."
"The CIA is prohibited from operating in health care facilities."
"Let’s talk about something other than the CIA."
"You have lost touch with reality, which is a symptom of your illness."
The Correct Answer is A
Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.
Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.
Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.
Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Redirecting the sibling’s concern to the patient minimizes and dismisses the sibling’s anxiety. This is not therapeutic.
Choice B reason: Schizophrenia has a genetic component, especially in identical twins, but environment and other factors also play roles. This response provides accurate information while reducing unnecessary fear.
Choice C reason: Offering referral may be helpful later, but it does not immediately address the sibling’s expressed concern or provide reassurance.
Choice D reason: Saying there is a 50-50 chance is inaccurate and unnecessarily alarming. The risk is higher in identical twins but not absolute.
Correct Answer is D
Explanation
Choice A reason: This response is factual but does not promote engagement or address the client’s passive stance. It emphasizes the nurse’s role without encouraging participation or collaboration from the older adult.
Choice B reason: This statement makes an assumption about the client’s feelings, labeling them as “angry,” which may not be accurate. It risks creating defensiveness and does not foster open communication or trust within the group.
Choice C reason: This response inappropriately offers group leadership to a member without assessing readiness or interest. It minimizes the therapeutic structure of the group and could confuse roles, making the group less effective.
Choice D reason: This option balances the acknowledgment of the nurse’s leadership role with an invitation for the client to share personal goals. It encourages involvement, respects autonomy, and helps build a therapeutic alliance by showing interest in what the older adult wants to accomplish.
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